Inspection · 2024-04-02
Date
2024-04-02
Complaint Related
No
Licensing Inspector
Florence Martus
(804) 389-0157
(804) 389-0157
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No
Areas Reviewed
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies.
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 4/2/24 from 9:45 a.m. to 2:12 p.m. with the Assistant Director. There were 114 children in care, ranging in age from five months to five-years-old, supervised by 20 staff. The children were observed in circle time and engaged in learning activities. Six child records and six staff records were reviewed. Eight medications and authorization forms were reviewed, and the center has seven staff current in Medication Administration Training (MAT). Required postings were observed. The attendance, menu, and emergency drill log were reviewed. The first aid kit, flashlight, and battery-operated radio were observed. The most recent Fire Inspection on file was dated 10/13/23 and the most recent Health Inspection on file was dated 10/14/23. Areas of non-compliance are identified in the Violation Notice. If you have questions regarding this inspection, please contact the Licensing Inspector, Beth Velke, at beth.velke@doe.virginia.gov or 804-629-8302.
Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by 5 p.m. on 5/3/24.
Violations
14Standard 22.1-289.035-B-2
Based on review of six staff records, the center did not obtain the results of a national fingerprint-based criminal history record check for one staff prior to employment.
Evidence: The fingerprint results on record for Staff #3, with an employment date of 3/18/24, were dated 3/22/24.
Evidence: The fingerprint results on record for Staff #3, with an employment date of 3/18/24, were dated 3/22/24.
Plan of Correction: Center will obtain fingerprints prior to staff start date.
Standard 22.1-289.035-B-4
Based on review of six staff records, it was determined that the center did not request the results of an out of state central registry background check within 30 days of employment for staff that has resided outside of Virginia in the preceding five years.
Evidence: Staff #5, with an employment date of 1/29/24, has resided in the state of Pennsylvania within the last 5 years, as indicated on the signed Sworn Disclosure Statement dated 1/24/24. There was no documentation of an out of state central registry request for Pennsylvania.
Evidence: Staff #5, with an employment date of 1/29/24, has resided in the state of Pennsylvania within the last 5 years, as indicated on the signed Sworn Disclosure Statement dated 1/24/24. There was no documentation of an out of state central registry request for Pennsylvania.
Plan of Correction: Center will obtain out of state central registry background checks for any staff who have lived outside the state of Virginia within the last 5 years.
Standard 8VAC20-770-60-B
Based on review of six staff records, the center did not obtain documentation of a completed sworn disclosure statement for each staff prior to date of employment.
Evidence: The record for Staff #3 with an employment date of 3/18/24, did not contain documentation of a sworn disclosure statement.
Evidence: The record for Staff #3 with an employment date of 3/18/24, did not contain documentation of a sworn disclosure statement.
Plan of Correction: Center will obtain sworn disclosure statement prior to date of employment.
Standard 8VAC20-770-60-C-2
Based on review six staff records; the center did not obtain results of a Virginia central registry search within 30 days of employment for all staff members.
Evidence: The record for Staff #5, with an employment date of 1/29/24, did not contain the results of a central registry search.
Evidence: The record for Staff #5, with an employment date of 1/29/24, did not contain the results of a central registry search.
Plan of Correction: Center will obtain Virginia central registry background checks within 30 days of employment.
Standard 8VAC20-780-160-A
Based on a review of six staff files, the center did not obtain documentation of a tuberculosis (TB) screening for staff at the time of employment and prior to coming in contact with children.
Evidence: The record for Staff #3, with an employment date of 3/18/24, did not contain documentation of a negative TB screening.
Evidence: The record for Staff #3, with an employment date of 3/18/24, did not contain documentation of a negative TB screening.
Plan of Correction: Center will ensure all staff have current TB test/screening before employment.
Standard 8VAC20-780-210-A
Repeat Violation
Based on record review and staff interviews, the center did not ensure that all program leaders had documentation of high school program completion or equivalent on file.
Evidence: The record for Staff #1, with a title of teacher, did not contain documentation of
education.
Based on record review and staff interviews, the center did not ensure that all program leaders had documentation of high school program completion or equivalent on file.
Evidence: The record for Staff #1, with a title of teacher, did not contain documentation of
education.
Plan of Correction: Center will obtain proof of education prior to staff employment.
Standard 8VAC20-780-240-A
Repeat Violations
Based on a review of six staff files, the center did not ensure that all staff complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence: The record for Staff # 1, with an employment date of 1/2/24, did not have documentation of completing the Preservice orientation course on file.
Based on a review of six staff files, the center did not ensure that all staff complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence: The record for Staff # 1, with an employment date of 1/2/24, did not have documentation of completing the Preservice orientation course on file.
Plan of Correction: Center will ensure all employees preservice trainings will be completed within 90 days of hire.
Standard 8VAC20-780-240-B
Repeat Violation
Based on review of six staff records, the center did not have documentation that staff completed orientation training no later than seven days of the date of assuming job responsibilities.
Evidence:
1. The record for Staff #3, with an employment date of 3/18/24 and the record for Staff #4, with an employment date of 1/15/24, did not contain documentation of completed orientation training on file at the time of inspection.
2. The record for Staff #5, with an employment date of 1/29/24, did not contain documentation of the date orientation was complete.
Based on review of six staff records, the center did not have documentation that staff completed orientation training no later than seven days of the date of assuming job responsibilities.
Evidence:
1. The record for Staff #3, with an employment date of 3/18/24 and the record for Staff #4, with an employment date of 1/15/24, did not contain documentation of completed orientation training on file at the time of inspection.
2. The record for Staff #5, with an employment date of 1/29/24, did not contain documentation of the date orientation was complete.
Plan of Correction: Center will do orientation training on new hires first day of employment.
Standard 8VAC20-780-330-B
Repeat Violation
Based on observation and measurement, the facility did not ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards.
Evidence: On the ?big? playground the mulch measured two inches in depth in the fall zones of the composite play structure including slide exits and stairs. Six inches of resilient surfacing is required.
Based on observation and measurement, the facility did not ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards.
Evidence: On the ?big? playground the mulch measured two inches in depth in the fall zones of the composite play structure including slide exits and stairs. Six inches of resilient surfacing is required.
Plan of Correction: Facilities has obtained quotes for more mulch. They have already completed a dig out and fill. They are now coming out to install a different type of border and more mulch.
Standard 8VAC20-780-40-L
Based on staff interviews, the facility failed to inform all staff who work with children of children's allergies, sensitivities, and dietary restrictions.
Evidence: In the Infant 2 classroom, Child #2 had a diagnosed allergy to peanuts and milk, requiring emergency medication. Staff were unaware of Child #2?s allergy to peanuts.
Evidence: In the Infant 2 classroom, Child #2 had a diagnosed allergy to peanuts and milk, requiring emergency medication. Staff were unaware of Child #2?s allergy to peanuts.
Plan of Correction: Management will inform staff of new allergies every time a student starts in their class. We will also write it on the current allergy list until the new list is posted.
Standard 8VAC20-780-40-M
Based on observation and interview, it was determined that the center did not maintain a current written list of all children?s allergies, sensitivities, and dietary restrictions.
Evidence: In the Infant 2 classroom, Child #2, had a diagnosed food allergy to peanuts and milk and was not listed on the allergy list.
Evidence: In the Infant 2 classroom, Child #2, had a diagnosed food allergy to peanuts and milk and was not listed on the allergy list.
Plan of Correction: Allergy list will be updated at a minimum of once a month. If a child with allergies is enrolled within that time management will add the child's allergy to the existing list.
Standard 8VAC20-780-510-P
Repeat Violation
Based on observation, review of documentation, and interview the center did not ensure that when an authorization for medication expired, that the parent was notified that the medication needed to be picked up within 14 days or the parent must renew the authorization and medications that were not picked up by the parent within 14 days were disposed of by the center.
Evidence: Child #8 had an emergency medication on site at the time of inspection and the corresponding parental medication authorization form expired on 1/30/24.
Based on observation, review of documentation, and interview the center did not ensure that when an authorization for medication expired, that the parent was notified that the medication needed to be picked up within 14 days or the parent must renew the authorization and medications that were not picked up by the parent within 14 days were disposed of by the center.
Evidence: Child #8 had an emergency medication on site at the time of inspection and the corresponding parental medication authorization form expired on 1/30/24.
Plan of Correction: Center will ensure medication and medication authorization forms are current and in date. When the form for medication expires the medication must be picked up by the parent within 14 days. If the medication is not picked up within 14 days the medication must be disposed of.
Standard 8VAC20-780-70
Repeat Violation
Based on a review of six staff records, the center did not maintain documentation of two or more references as to character and reputation as well as competency were checked before employment, including dates of contact and signature of person making the call when references were obtained over the phone.
Evidence:
1. The record for Staff # 1, with an employment date of 1/2/24, Staff #2, with an employment date of 1/15/24, Staff #3, with an employment date of 3/18/24, Staff #4, with an employment date of 1/15/24, and Staff #6, with an employment date of 1/29/24, did not contain documentation of two references.
2. The record for Staff #5, with an employment date of 1/29/24, did not contain documentation of the person making the call and the date the references were obtained.
Based on a review of six staff records, the center did not maintain documentation of two or more references as to character and reputation as well as competency were checked before employment, including dates of contact and signature of person making the call when references were obtained over the phone.
Evidence:
1. The record for Staff # 1, with an employment date of 1/2/24, Staff #2, with an employment date of 1/15/24, Staff #3, with an employment date of 3/18/24, Staff #4, with an employment date of 1/15/24, and Staff #6, with an employment date of 1/29/24, did not contain documentation of two references.
2. The record for Staff #5, with an employment date of 1/29/24, did not contain documentation of the person making the call and the date the references were obtained.
Plan of Correction: Management will ensure all staff have at least two reference checks that are completed prior to hire date and completed with signature and date.
Standard 8VAC20-780-80-A
Based on review of the written attendance record, the center did not maintain a written record of daily attendance for each group of children documenting arrival and departure of each child in care as it occurs.
Evidence:
1. In the Infant 1 classroom, there were nine children present however, only eight children were signed in on the written attendance.
2. In the two-year classroom, there were 20 children present, however, only 17 children were signed in on the written attendance.
Evidence:
1. In the Infant 1 classroom, there were nine children present however, only eight children were signed in on the written attendance.
2. In the two-year classroom, there were 20 children present, however, only 17 children were signed in on the written attendance.
Plan of Correction: Management will retrain classrooms on proper written daily attendance and name to face protocol. Children's arrival and departure times will be documented.